Alcohol (OH) and the Skin – Malnutrition (For professionals)

Malnutrition

• Zinc
• Clinically:

1. erythematous crusting erosive sometimes bullous dermatitis
2. periorificial: buccal, nasal, palpebral, anal, vulval, genital, flexural
3. progressive alopecia

• diagnosis and treatment: reduced blood Zn and alkaline phosphatase, sometimes also reduced non esterified essential fatty acids (linoleic and arachidonic acid). IV or oral by zinc salts (gluconate, sulfate) leads to spectacular cures.

• Essential Fatty Acids

1. sometimes associated with Zinc deficiency
2. Clinically: leads to dry ichthyotic skin or eczema craquele and is associated with growth retardation.
3. diagnosis and treatment: blood dosage. Treatment can be topical, IV or oral.

• Vitamin PP
• composed of nicotinic acid (niacin) and nicotinic amide (nicotinamide)
• its precursor is tryptophane
• its metabolism needs the vitaminic coenzymes B1, B2 and B6.
• Clinically = pellagra

1. dermatitis: dusky red erythema appearing quickly on exposed skin accompanied with edema, fine cracked skin followed by bullous hemorrhagic sloughings slowly resolving leaving behind thin, pigmented skin.
2. diarrhea: often preceeded by stomatitis and glossitis.
3. dementia: apathic, depression. Sensorial deficiency is present in severe cases

• diagnosis and treatment: PP dosage can sometimes be normal despite symptoms. Treatment by Nicotinamide 500mg/d IV. Skin signs are the first to disappear, followed by the neurological and digestive ones.

• Vitamin B6 (pyridoxin)

1. Clinically = peri-orificial seborrhoeic dermatitis.
2. diagnosis: charge test with tryptophane (measurement of urinary xanthurenic acid): efficient.
3. Treatment with Vitamin B6 orally or IV (1g/d) leads to healing in a few months.

• Vitamin B2 (riboflavin)
• Clinically :

1. oral: fissural cheilitis and perleche, angular stomatitis, glossitis.
2. genital: peri-orificial erythema
3. ocular: blepharitis and conjunctivitis

• diagnosis: riboflavin dosage can’t be relied on.
• Only Riboflavin IV (20-40mg/d) treatment followed by rapid improvement confirms the diagnosis

• Vitamin A
• Clinically

1. rough dry scaly wrinkled skin
2. hypohidrosis and sebaceous atrophy
3. follicular hyperkeratosis (non specific)(=phrynoderma) of limbs, nape of neck, shoulders, trunk
4. other systems: diminished night vision

• Diagnosis and treatment: diagnosis by dosage of vitamin A or by proof treatment with vitamin A 50000 units/d (cured in a few months).

• Vitamin C (ascorbic acid) (scurvy)
• plays a role in collagen, iron, sulfur, tyrosine and folic acid metabolism
• Clinical features of scurvy:

1. follicular keratosis
2. corkscrew hairs
3. perifollicular hemorrhage
4. extensive polychrome purpura with a sclerodermiform oedema. Sometimes hemorrhagic hypodermitis.
5. glossitis
6. hypertrophic and hemorrhagic gingivitis
7. teeth fall

• Diagnosis and treatment: Intraleucocyte dosage of Vit C can be normal in the beginning. Treatment with ascorbic acid orally or IV 1-2g/d

• Vitamin K

1. plays a role in the synthesis of coagulation factors II VII IX X.
2. Clinically: purpura
3. Treatment: intramuscular Vit K injection is sometimes followed by an inflammatory eczema-like reaction which can evolve to scleroderma-like plaques and necroses.

• Iron (excess by intoxication or storage (hemochromatosis)):

1. Clinically: melanoderma ; if diffuse associated with atrophic skin, hypopilosity, thin hair, leuconychia, koilonychias should lead to the suspicion of familial Hemochromatosis.

Bibliography: Dermatologie et Infections Sexuellement Transmissibles, 4th Edition